[THE INFLUENCE OF NASOTRACHEAL INTUBATION ON NASAL RESISTANCE].
Harefuah. 2020 Feb;159(1):113-116
Authors: Neustaedter BS, Greenberg-Dotan S, Kaplan DM, Elsaied S, Slovik Y
INTRODUCTION: Tracheal intubation is a vital and common procedure during surgical care. The tracheal tube may be inserted orally or trans-nasally. Nasal intubation enables a non-restricted approach for oral and oropharyngeal regions. Thus, nasotracheal intubation is more suitable for surgeries such as uvulopalatopharyngoplasty treating obstructive sleep apnea. Obstructive sleep apnea is an independent risk factor for postoperative cardiorespiratory complications. Thus, meticulous treatment during and post-operatively is needed keeping the upper airway open including the nasal cavity. In several studies, nasotracheal intubation resulted in disruption of the nasal mucosa.
OBJECTIVES: The objective of this study is evaluating the developing nasal resistance post nasotracheal intubation and comparing it to nasal resistance post-orotracheal intubation. To our knowledge, this is the first data on nasal obstruction following nasal intubation.
METHODS: Forty-four candidates, for elective non-head and neck procedures were randomized into two groups: oral intubation group and nasal intubation group. The nasal resistance of all participants was measured by anterior rhinomanometry upon the recommendation of the standardization committee on objective assessment of the nasal airway. Statistical analysis with paired T test, Chi square and McNemar's test was performed. Statistical significance was evaluated at P≤0.05.
RESULTS: There were no differences between the study groups regarding nasal resistance before and after intubation. However, nasotracheal intubation was found to disrupt the normal nasal cycle of the nasal mucosa.
CONCLUSIONS: Nasotracheal intubation does not negatively affect nasal resistance in the early postoperative period.
DISCUSSION: Nasotracheal intubation does not affect nasal resistance and it seems to be safe for OSA patients. More research has to be conducted to evaluate the nasal resistance in patients who undergo oral and nasal surgeries.
PMID: 32048491 [PubMed - indexed for MEDLINE]
High-Risk Emergency Laparotomy in Australia: Comparing NELA, P-POSSUM, and ACS-NSQIP Calculators.
J Surg Res. 2020 02;246:300-304
Authors: Hunter Emergency Laparotomy Collaborator Group, Hunter Emergency Laparotomy Collaborator Group
BACKGROUND: The National Emergency Laparotomy Audit (NELA) highlights the importance of identifying high-risk patients due to the potential for significant morbidity and mortality. The NELA risk prediction calculator (NRPC) was developed from data in England and Wales and is one of several calculators available. We seek to determine the utility of NRPC in the Australian population and compare it with Portsmouth Physiological and Operative Severity Score for the enumeration of mortality and Morbidity (P-POSSUM) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) calculators.
METHODS: A retrospective review of all emergency laparotomies undertaken at four Australian centers was performed between January 2016 and December 2017. Data extracted from patient records were used to calculate NRPC, ACS-NSQIP, and P-POSSUM scores for 30-day mortality risk. The sensitivity of NRPC was assessed using the NELA high-risk cohort score of ≥10% and this was compared with the other two calculators.
RESULTS: There were 562 (M = 261, mean age = 66 [±17] y) patient charts reviewed in the study period. 59 patients died within 30 d (10.5%). NRPC was able to identify 52 (sensitivity = 88.1%) of these as being within the high-risk group. Using the NELA high-risk cutoff, NRPC identified 52 deaths of 205 (25.4%) high-risk patients, P-POSSUM identified 46 of 245 (18.8%), and ACS-NSQIP identified 46 of 201 (22.9%). Using the McNemar test, no significant difference was noted between NRPC and P-POSSUM (P = 0.07) or NRPC and ACS-NSQIP (P = 0.18).
CONCLUSIONS: In the Australian context, the NRPC is a highly sensitive and useful tool for predicting 30-day mortality in high-risk emergency laparotomy patients and is comparable with P-POSSUM and ACS-NSQIP calculators.
PMID: 31648068 [PubMed - indexed for MEDLINE]
Older Patients With Severe Traumatic Brain Injury: National Variability in Palliative Care.
J Surg Res. 2020 02;246:224-230
Authors: Hwang F, Pentakota SR, Glass NE, Berlin A, Livingston DH, Mosenthal AC
BACKGROUND: Older patients with traumatic brain injury (TBI) have higher mortality and morbidity than their younger counterparts. Palliative care (PC) is recommended for all patients with a serious or life-limiting illness. However, its adoption for trauma patients has been variable across the nation. The goal of this study was to assess PC utilization and intensity of care in older patients with severe TBI. We hypothesized that PC is underutilized despite its positive effects.
MATERIALS AND METHODS: The National Inpatient Sample database (2009-2013) was queried for patients aged ≥55 y with International Classification of Diseases, Ninth Revision codes for TBI with loss of consciousness ≥24 h. Outcome measures included PC rate, in-hospital mortality, discharge disposition, length of stay (LOS), and intensity of care represented by craniotomy and or craniectomy, ventilator use, tracheostomy, and percutaneous endoscopic gastrostomy.
RESULTS: Of 5733 patients, 78% died in hospital with a median LOS of 1 d, and 85% of the survivors were discharged to facilities. The overall PC rate was 35%. Almost 40% of deaths received PC, with nearly half within 48 h of admission. PC was used in 26% who had neurosurgical procedures, compared with 35% who were nonoperatively managed (P = 0.003). PC was associated with less intensity of care in the entire population. For survivors, those with PC had significantly shorter LOS, compared with those without PC.
CONCLUSIONS: Despite high mortality, only one-third of older patients with severe TBI received PC. PC was associated with decreased use of life support and lower intensity of care. Significant efforts need to be made to bridge this quality gap and improve PC in this high-risk population.
PMID: 31606512 [PubMed - indexed for MEDLINE]
Mode of Transport and Trauma Activation Status in Admitted Pediatric Trauma Patients.
J Surg Res. 2020 02;246:153-159
Authors: Rubens JH, Ahmed OZ, Yenokyan G, Stewart D, Burd RS, Ryan LM
BACKGROUND: Injured children who arrive by self-transport to the emergency department (ED) may receive delayed or inadequate care. We studied differences in demographics, clinical characteristics, and trauma activation status for admitted pediatric trauma patients based on arrival by self-transport or Emergency Medical Services (EMS).
MATERIALS AND METHODS: We performed a retrospective cohort study at two level I pediatric trauma centers.
INCLUSION CRITERIA: <15 y old with blunt or penetrating injury. We used univariate and multivariate logistic regression analyses to determine associations between trauma activation, ED length of stay (LOS), and hospital LOS with demographic and clinical characteristics.
RESULTS: We identified 1161 patients: 40.1% arrived by self-transport and 59.9% by EMS. Self-transport patients were less likely to have an abnormal Glasgow Coma Scale score < 15 (2.1% versus 22.0%, P < 0.001) and Injury Severity Score > 15 (2.4% versus 11.7%, P < 0.001). Trauma activation was initiated in 52.5% of patients, occurring less often in self-transport than EMS patients (2.4% versus 86.2%, P < 0.001). Trauma activation rate was negatively associated with arrival by self-transport (odds ratio [OR] 0.001, 95% CI 0.00-0.003), positively associated with Glasgow Coma Scale <15 (OR 25.9, 95% CI 6.6-101.2) and site (OR 15.4, 95% CI 6.3-37.5) but not with Injury Severity Score >15 (OR 2.8, 95% CI 0.8-9.2). Self-transport arrival was associated with longer ED LOS (estimated regression slope 0.47, 95% CI 0.13-0.82).
CONCLUSIONS: Almost half of admitted pediatric trauma patients arrived by self-transport; however, trauma team activation rarely occurs for these patients. Trauma team activation may be underutilized in self-transport patients with injuries resulting in hospital admission.
PMID: 31586889 [PubMed - indexed for MEDLINE]
Practice Variation in Vena Cava Filter Use Among Trauma Centers in the National Trauma Database.
J Surg Res. 2020 02;246:145-152
Authors: Gilligan TC, Cook AD, Hosmer DW, Hunter DC, Vernon TM, Weinberg JA, Ward J, Rogers FB
BACKGROUND: Agreement regarding indications for vena cava filter (VCF) utilization in trauma patients has been in flux since the filter's introduction. As VCF technology and practice guidelines have evolved, the use of VCF in trauma patients has changed. This study examines variation in VCF placement among trauma centers.
MATERIALS AND METHODS: A retrospective study was performed using data from the National Trauma Data Bank (2005-2014). Trauma centers were grouped according to whether they placed VCFs during the study period (VCF+/VCF-). A multivariable probit regression model was fit to predict the number of VCFs used among the VCF+ centers (the expected [E] number of VCF per center). The ratio of observed VCF placement (O) to expected VCFs (O:E) was computed and rank ordered to compare interfacility practice variation.
RESULTS: In total, 65,482 VCFs were placed by 448 centers. Twenty centers (4.3%) placed no VCFs. The greatest predictors of VCF placement were deep vein thrombosis, spinal cord paralysis, and major procedure. The strongest negative predictor of VCF placement was admission during the year 2014. Among the VCF+ centers, O:E varied by nearly 500%. One hundred fifty centers had an O:E greater than one. One hundred sixty-nine centers had an O:E less than one.
CONCLUSIONS: Substantial variation in practice is present in VCF placement. This variation cannot be explained only by the characteristics of the patients treated at these centers but could be also due to conflicting guidelines, changing evidence, decreasing reimbursement rates, or the culture of trauma centers.
PMID: 31580984 [PubMed - indexed for MEDLINE]